A simplified Fazekas scale for efficient assessment of white matter hyperintensities

White matter hyperintensities (WMH) are key neuroimaging markers of cerebral small vessel disease (CSVD) and are associated with neuropsychiatric symptoms in older adults. Although the Fazekas visual rating scale is widely used in research, its clinical adoption remains limited. Therefore, we developed a simplified Fazekas visual rating scale (sFazekas) for overall WMH assessment to facilitate clinical application.

We randomly selected 900 participants from three MRI scanners and evaluated the reliability and scoring efficiency of sFazekas versus the Fazekas scale. Then, all participants were grouped according to the sFazekas scores, and intergroup differences among the different scores were analyzed. Next, we examined correlations among the sFazekas, the Fazekas, and WMH volume. Finally, we explored associations between the sFazekas and vascular risk factors related to CSVD.

The sFazekas demonstrated excellent inter-rater reliability (κ = 0.851) and required significantly less time to complete than the conventional Fazekas (p < 0.01). Significant differences in age, WMH volume, and vascular risk factors were observed across sFazekas score groups (p < 0.01). The sFazekas scores were strongly correlated with Fazekas scores for both deep and periventricular white matter, as well as with WMH volume (p < 0.001). Ordinal logistic regression indicated that age, hypertension, diabetes mellitus, and a history of stroke were independent predictors of higher sFazekas scores (p < 0.001).

The simplified Fazekas visual rating scale (sFazekas) demonstrates reliability comparable to the conventional Fazekas scale, with the practical advantage of shorter scoring time, suggesting its potential utility in the clinical assessment of overall white matter hyperintensity burden in patients with cerebral small vessel disease.